Horizon Home Health Magic Valley

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on policy review, medical record review, and staff interview, it was determined the HHA failed to follow its own established policy for investigating and responding to a serious adverse event for 1 of 1 sampled patient who experienced an unexpected death (Patient #1). This failure to investigate and possibly identify issues, put all HHA patients at risk of additional harm and resulted in incomplete QAPI data. Findings include: The HHA had a policy titled, “Incident Reporting” with revised date of December 2025 with the stated purpose: “To define the reporting, follow-up, and feedback process for incidents involving patients and organization personnel.” The policy continued, “5. To investigate and respond to serious adverse events, in accordance with accrediting bodies standards.” The policy defines serious adverse event as “an unexpected occurrence involving death.” The policy continued, “The Performance Improvement Coordinator will review the incident reports and conduct follow-up as indicated. Corrective actions will be implemented and evaluated for effectiveness as indicated.” This policy was not followed. An example included: Patient #1 was 70-year-old man who was admitted to the HHA on 4/11/25 for skilled nursing services with “goals of medication management, community engagement and understanding of conditions and how to prevent rehospitalization. The patient received an initial RN visit on 4/11/25. Patient #1’s initial visit documented history of falls, decline in mental, emotional or behavioral status in the past 3 months, reported or observed history of difficulty complying with any medical instructions, currently taking 5 or more medication, currently reports exhaustion and other risks.” In addition, the initial visit documented Alcohol Dependence and Post Traumatic Stress Disorder with symptoms listed as “2-controlled with difficult, affecting daily functioning, patent needs ongoing monitoring.” Patient #1’s chart documented “alcohol precautions” with no documented discussion or education on alcohol use with numerous psychiatric medications and oxygen need of 2LPM. Frequency/duration of visits in Patient #1’s chart documented “SN 1WK2” (one skilled nursing visit per week for 2 weeks). A Licensed Practical Nurse (LPN) visit on 4/17/25 documented the patient was unsteady, weak, and occasionally confused. The record further documented drops in blood pressure, the LPN’s encouragement for the patient to seek ED evaluation. On 4/21/25, the record documented a call reporting the patient was “deceased.” No documentation was found in Patient #1’s record or in incident reports indicating the patient’s death was reported as an adverse event. The HHA could not provide documentation of an incident report, investigation, review, or corrective actions implemented in response to the death. During an interview on 3/11/26 beginning at 3:30 PM, the DCN reviewed Patient #1’s medical record and incident reports. The DCN stated Patient #1 died at home on 4/18/25 after being in the ED for only a few hours on 4/17/25 and confirmed there were no additional home visits prior to his death. The DCN, who was not in the position at the time of the event, reported she was not aware of any reporting, investigation, or follow‑up conducted in response to Patient #1’s death. The facility failed to record, investigate, or implement corrective actions for a serious adverse event as required by its own policy.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on medical record review, infection control records, quality reporting records, observational visits, and staff interviews, it was determined the agency failed to capture a patient infection in 1 of 10 Patients (Patient #9) whose records were reviewed. This had the potential for infection control measurements to be inaccurate leading to quality measures to be inaccurate. Findings include: Patient #9 was an 89-year-old female admitted to the HHA on 1/8/26 for wound care. Patient #9’s medical history included leg ulcers, dementia, incontinence, and chronic kidney disease. Patient #9 resided in an assisted living facility. An observational visit with the RN was conducted with Patient #9 on 3/11/26 beginning at 11:30 AM. After wound care, the RN spoke with facility staff and noted the Patient had completed her round of Macrobid on 3/4/26 which she had taken for 5 days due to a reported UTI. The Infection Control Coordinator, also the DCN, was interviewed on 3/4/26 beginning at 3:20 PM and Patient #9’s medical record was reviewed in her presence. She was asked if Patient #9’s most recent UTI was captured in the incident reports. The DCN confirmed this latest infection of Patient #9 was not captured. She confirmed patient infections of any kind were reportable as incidents. Patient infections were not captured consistently.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on medical record review, observational visits, and staff interviews, it was determined 1 of 10 patients (Patient #7) whose records were reviewed, did not receive all services requested on their plan of care. This had the potential to leave patient needs to remain unmet. Findings include: Patient #7 was a 70-year-old female admitted to the HHA on 2/17/26 for wound care. Patient #7’s initial plan of care included a Social Worker evaluation. An observational visit with the bath aide was conducted on 3/11/26 at 2:30 PM. Patient #7 stated she was expecting a Social Worker visit but had not received one yet. An interview was conducted with the DCN on 3/11/26, beginning at 3:00 PM and Patient #7’s chart was reviewed in her presence. She confirmed the initial order included a social work evaluation. She also confirmed there had been no social work visit for Patient #7. The plan of care was not followed.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on medical record review and staff interview, it was determined the agency failed to ensure the POCs included all interventions, measurable outcomes, medications, and goals for 2 of 11 patients (Patient #1 and #5) whose records were reviewed. This failure resulted in incomplete POCs and had the potential to result in unmet patient needs. Findings include: Record review showed Patient #1, a 70‑year‑old man, was admitted to the HHA on 4/11/25 for skilled nursing services, including medication management and education. The initial RN assessment on 4/11/25 documented multiple risk factors including a history of falls, decline in mental/emotional/behavioral status within the past three months, difficulty complying with medical instructions, use of five or more medications, reported exhaustion, and other risks. The assessment also documented Alcohol Dependence issues and PTSD with symptoms described as “2-controlled with difficulty, affecting daily functioning, patient needs ongoing monitoring.”Patient #1’s record included “alcohol precautions,” but no documentation of education or interventions addressing alcohol use in combination with psychiatric medications or the patient’s prescribed oxygen at 2 LPM. The POC documented a visit frequency of “SN 1WK2” (one skilled nursing visit per week for 2 weeks). Patient #1’s record did not include documentation of goals or interventions related to PTSD or alcohol dependence. During an interview on 3/11/26 beginning at 3:30 PM, the RN who completed the initial visit stated confirmed neither alcohol dependence nor PTSD were addressed in the POC or interventions provided. Patient #1 was discharged from the HHA on 4/21/25 following his death on 4/18/25. 2. Record review showed Patient #5, a 72‑year‑old female, was admitted to the HHA on 1/28/26 with the primary diagnosis of Chronic Obstructive Pulmonary Disease as well as additional mental health diagnoses, including major depressive disorder and delusional disorder. Both mental health conditions were documented as “2 – Symptoms controlled with difficulty, affecting daily functioning, patient needs ongoing monitoring.” Additional risks documented at the start of care included a decline in mental, emotional, or behavioral status within the past three months and the patient was “confused and disorganized and has a hard time focusing on nurse.” Documentation of goals or treatment plans addressing the patient’s delusional disorder or major depressive disorder were found in the POC. Review of RN and PT visit notes dated 1/30/26, 2/4/26, 2/11/26, and 2/19/26 showed no interventions, assessments, or monitoring related to the patient’s mental health diagnoses. During an interview on 3/11/26 beginning at 3:30 PM, the Director of Clinical Nursing (DCN) reviewed Patient #5’s medical record and confirmed the POC did not include interventions specific to the patient’s mental health diagnoses. The DCN further confirmed there was no documentation showing depression was monitored during RN or PT visits. The facility failed to ensure all pertinent diagnoses were addressed in the POC and appropriate interventions were provided.”